Significance of serum lactic dehydrogenase in stages B and C non-seminomatous testis tumors

Serum Tumour Markers in Testicular Germ Cell Tumours: Frequencies of Elevated Levels and Extents of Marker Elevation Are Significantly Associated with Clinical Parameters and with Response to Treatment

Introduction

Although serum tumor markers beta human chorionic gonadotropin (bHCG), alpha-fetoprotein (AFP), and lactate dehydrogenase (LDH) are well-established tools for the management of testicular germ cell tumours (GCTs), there are only few data from contemporary cohorts of primary GCT patients regarding these biomarkers. Our aim was to evaluate marker elevations in testicular GCTs and to document their associations with various clinical characteristics.

Patients and Methods

A total of 422 consecutive patients with GCTs were retrospectively analysed regarding serum levels of bHCG, AFP, and LDH during the course of treatment. Additionally, the following characteristics were recorded: histology, age, laterality, clinical stage (CS), pT-stage, and tumour size. Marker elevations were first tabulated in dichotomized way (elevated: yes/no) in various subgroups and second as continuous measured serum values. Descriptive statistical methods were employed to look for differences among subgroups and for associations of elevations with clinical parameters.

Results

In all GCT patients, the frequencies of elevated levels of bHCG, AFP, LDH, and bHCG or AFP were 37.9%, 25.6%, 32.9%, and 47.6%; in pure seminomas 28%, 2.8%, 29.1%, and 30.3%; and in nonseminoma 53.0%, 60.1%, 38.7%, and 73.8%. Significant associations were noted with pT-stages >pT1, clinical stages >CS1, tumour size, and younger age. Frequencies of marker elevations dropped significantly after treatment, but LDH levels remained elevated in 30.5%-34.1%. Relapsing patients (n=27) had elevated levels of bHCG, AFP, and LDH in 25.9%, 22.2%, and 29.6%, respectively, thirteen of whom with a changed marker pattern.

Conclusions

The classical GCT-biomarkers correlate with treatment success. Clinical utility is limited due to proportions of < 50% of patients with elevated levels and the low specificity of LDH. The elevation rates are significantly associated with histology, clinical and pT-stages, tumour size, and younger age. Individual marker patterns may change upon relapse. Clinically, ideal biomarkers are yet to be found.

Elevated lactate dehydrogenase isoenzyme 1 as a tumour marker in patients with germ cell testicular tumours

In a series of 50 patients with testicular tumours evaluated prior to orchidectomy, 12 out of 19 with pure seminoma and seven out of 31 with non-seminomatous or mixed seminomatous and non-seminomatous germ cell tumours had elevated plasma lactate dehydrogenase isoenzyme 1 concentrations. In contrast, seven of the 19 seminoma patients had elevated serum human chorionic gonadotrophin (hCG) concentrations and 25 of the 31 non-seminomatous and mixed seminomatous and non-seminomatous germ cell tumour patients had elevations of hCG and/or alpha-fetoprotein. Using these three markers, 12 out of 19 seminoma patients and 27 out of 31 non-seminomatous or mixed seminomatous and non-seminomatous tumour patients were positive for one or more of these tumour markers.

Biological markers in urologic cancer

Tumor markers (TMs) play an important part in the management of urologic cancer. Alpha-fetoprotein, human chorionic gonadotropin, and occasionally lactic dehydrogenase serological determinations have become indispensable in the management of nonseminomatous germ cell testicular tumor patients, particularly after initial therapy, whereas human chorionic gonadotropin and probably placental alkaline phosphatase are important in seminoma. Prostatic acid phosphatase has long been important for the monitoring of patients with carcinoma of the prostate. The availability of the immunologic assays instead of the enzymatic assays has improved sensitivity somewhat but clinical interpretation has also become more complicated. Prostatic specific antigen is already an important tissue marker for carcinoma of the prostate and promises to be an important serological one, possibly surpassing prostatic acid phosphatase in importance. Analysis of DNA by automated flow cytometry is becoming important in the early detection and follow-up of bladder cancer patients. Studies concerning the tissue analysis of blood group antigens in bladder cancer continue to demonstrate that this approach can provide unique clinical information and interesting biological insights, but its role in routine clinical management remains to be determined. Currently, TMs have little clinical significance in renal cell carcinoma, but the availability of monoclonal antibodies to renal cell carcinoma preferential antigens may change this deficiency soon. In fact, in the near future, monoclonal antibodies will probably reveal many new substances for many urological cancers which can be used for markers serologically, histochemically, and, with their corresponding antibody, for radioimmune imaging and possibly immunotherapy. Now, as then, familiarity with the nuances of the marker and good clinical judgement will be essential.

Immunosuppressive acidic protein in patients with testicular cancer

Serum immunosuppressive acidic protein was compared to lactic dehydrogenase as a marker for testicular cancer in 54 patients with testicular cancer, 62 with benign urological diseases and 203 healthy controls. The mean value of serum immunosuppressive acidic protein in patients with testicular cancer (598 +/- 293 micrograms. per ml.) was statistically higher than that in patients with benign disease (429 +/- 163 micrograms. per ml.) and healthy controls (368 +/- 73 micrograms. per ml.). There were statistically significant differences in serum immunosuppressive acidic protein levels between controls and patients with stage 2 (p less than 0.0001) or stage 3 (p less than 0.001) testicular cancer, and between those with stage 1 and stage 2 (p less than 0.0001) or stage 3 (p less than 0.001) disease, respectively. The usefulness of immunosuppressive acidic protein as a marker for testicular cancer also was compared to that of lactic dehydrogenase. Immunosuppressive acidic protein and lactic dehydrogenase levels were elevated almost equally in patients with stage 2 or 3 disease (range 71 to 92 per cent). However, immunosuppressive acidic protein levels were elevated in only 3 of 25 patients with stage 1 cancer (12 per cent), compared to 11 of 25 (44 per cent) with elevated lactic dehydrogenase levels. Immunosuppressive acidic protein was correlated better with tumor stage. In conclusion, serum immunosuppressive acidic protein determinations may be useful in patients with testicular cancer for staging, monitoring treatment results and predicting recurrence.

Lactate dehydrogenase as a marker for testicular germ-cell tumours

One hundred and eighty-four patients with testicular germ-cell tumours, 92 with seminoma and 92 with non-seminomatous germ-cell tumours (NSGCT) had total lactate dehydrogenase (LD) assay performed at the time of initial staging following orchidectomy. The proportion of patients with elevated plasma LD and the mean plasma LD increased with advancing stage and increasing tumour bulk for both seminoma and NSGCT. Of patients receiving cytotoxic chemotherapy, 87.5% with seminoma and 63% with NSGCT had elevated plasma LD with subsequent levels reflecting regression or progression of disease. Elevated plasma LD levels were seen in four of seven seminoma, and in 18 of 30 NSGCT patients relapsing after primary treatment. The LD assay provides useful information, and complements the routine measurement of alphafetoprotein (AFP) and beta human chorionic gonadotrophin (beta hCG) in the management of patients with testicular germ-cell tumours.

Tumor markers: value and limitations in the management of cancer patients

Sixteen tumor markers are reviewed, and measured to the ideal: produced by the tumor cell alone absent in health and in benign disease present in all patients with a given malignancy level in the blood representative of tumor mass detectable in occult disease. The only marker that approaches the ideal is human chorionic gonadotropin (HCG) in gestational trophoblastic tumors. In this malignancy, the HCG level suggests the diagnosis and stage, confirms response to therapy, and predicts relapse. The three most widely used and intensely studied tumor markers are carcinoembryonic antigen (CEA), alphafetoprotein (AFP), and HCG. CEA cannot be used in screening for cancer, but in carcinoma of the colon its elevation preoperatively increases the likelihood of advanced disease and postoperative recurrence. Postoperatively, elevated titers are often but not invariably associated with recurrent disease. AFP and HCG are useful in the management of nonseminomatous germ cell testicular tumors. Like CEA, they cannot be used for screening. They are more likely to be increased with advancing stage, and after therapy rising levels almost always mean recurrent disease. Some markers are valuable in specific circumstances, such as calcitonin in screening for familial medullary carcinoma of the thyroid. In multiple myeloma, immunoglobulins are useful in determining the tumor mass and response to therapy. In neuroblastoma, catecholamine metabolites are useful primarily in making the diagnosis. In some malignancies, the absence of effective therapy lowers the value of the marker, as for AFP in hepatoma. The remaining markers are too unreliable or too little studied to be useful in the management of an individual patient with cancer. The purpose of this paper is to provide the clinician with an understanding of the limitations of the present tumor markers that will lead to wiser use of the tests, and to provide standards to which future tumor markers should be measured.

Resection of pulmonary metastases from nonseminomatous testicular tumors. Correlation of clinical and histological features with treatment outcome

Clinical and histological correlates of survival in patients undergoing complete resection of pulmonary metastases from nonseminomatous testicular carcinoma were determined in 25 Stage C patients aged 17-38 years treated from 1969-1978. All patients had orchiectomy and retroperitoneal lymphadenectomy. Nineteen patients received combination chemotherapy before resection, and all received chemotherapy after resection. Three patients had four additional thoracotomies for pulmonary recurrence. Survival was measured from time of first thoracotomy to time of last followup or death. Actuarial survival for the entire group at one, two, and five years was 80, 63, and 59%, respectively. Median follow-up of the survivors was 3.5 years. Patients in low tumor burden groups such as those with no tumor in retroperitoneal nodes, with unilateral metastases, or with single metastases had better prognosis, as did patients whose primary tumors were moderately well differentiated. Characteristics of pulmonary metastases that favorably influenced the prognosis were the presence of mature teratoma, presence of few mitoses, lack of mononuclear infiltrate, and lack of desmoplastic response. These findings confirm the effectiveness of multimodality therapy which includes the resection of pulmonary metastases for Stage C nonseminomatous carcinoma of the testes. In addition, they suggest that consideration should be given to the stratification of prospective clinical trials on the basis of tumor burden and histologic characteristics of the primary and metastatic lesions.

Role of lactate dehydrogenase isoenzymes in testicular cancer

Changes in the serum levels of lactate dehydrogenase have been noted to reflect growth and/or regression in many patients with testicular tumors, but they were nonspecific. However, elevation of the first of the LDH isoenzymes (LD-1) has been found specific to testicular cancer among all neoplasms. In this prospective preliminary report of 19 testicular cancer patients serum LD-1 was found to be normal in 4 patients with no tumor present. Therefore, there were no false positive findings. Of 6 patients with microscopic disease, LD-1 level was normal. Of 9 patients with gross disease, 5 had elevated serum LD-1 and 4 had normal LD-1. Of 4 patients with seminoma, 3 had elevated LD-1 while all 4 patients had no other elevated markers. It appears that elevation of serum LD-1 provides a marker for seminoma and a marker with some specificity for testicular cancer.